Pregnancy Form

Name

Address

Phone

Email Address

Date of Birth

Emergency Contact Name & Number

OBGYN/Midwife Name, Clinic Name & Phone Number

Referred By

Occupation

Week of Pregnancy

Due Date

Are you a high risk pregnancy?

Yes

*****If yes, please have physician note authorizing therapeutic massage*****

Are you expecting

One Baby

Multiples

How would you rate your overall health?

Excellent

Good

Fair

Poor

Have you ever received a professional massage?

Yes

Reason for seeking massage

In order to better address your goals, please state your specific concerns and approximate date of onset

What is your exercise level?

Please check any complications or conditions related to this pregnancy

Waiver of Liability and Consent to have Massage

I agree to submitting intake forms online and waive all claims.

I agree to hold harmless Relax & Be Well, LLC, of all claims, including Andree Strauss, her spouse, her heirs, her property and associations.

I understand that my information will not be shared with anyone outside of Relax & Be Well, LLC without my written consent.

I understand that I need a physicians approval for therapeutic massage if I am a high risk pregnancy.

I understand that if I have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from my primary care provider may then be required prior to my massage session. If I experience any pain or discomfort during my massage, I will inform the practitioner immediately.

I understand that the massage therapist cannot diagnose any medical conditions, but they can recommend seeing a medical doctor or medical specialist with any concerns.

I understand that if I choose to have a cupping session (alone or added to massage) that there may be visible marks left on my body, that may last up to a couple of weeks and that cupping is contraindicated on the abdomen, lower back and ankles during pregnancy.

I have answered the above information to the best of my knowledge and will let the practitioner know if anything changes with my health history.

Cancellation Policy

I understand that I will be charged 100% of my scheduled service fee if I cancel my appointment less than 24 hours before my scheduled time.

Relax & Be Well

Therapeutic Massage and Wellness Coaching

Victoria, MN
andree@relaxandbewell.com
(952) 212-3769
bewellcoachmark@gmail.com
(952) 491-1429

Relax & Be Well

Therapeutic Massage and Wellness Coaching

Victoria, MN andree@relaxandbewell.com (952) 212-3769 bewellcoachmark@gmail.com (952) 491-1429

Victoria, MN
andree@relaxandbewell.com
(952) 212-3769
bewellcoachmark@gmail.com
(952) 491-1429